
Dóra Regőczi, Glasgow Caledonian University, @DoraRegoczi
About stroke
Stroke is a serious life-threatening medical condition which occurs when a part of the brain cannot get enough oxygen due to insufficient blood supply caused by a blockage or is damaged by a bleed. In the UK, there are over 100,000 strokes every year and it is a leading cause of disability (Stroke Association, 2018). The effects of a stroke depend on where it takes place in the brain and how big the damaged area is. Stroke survivors are often left to deal with serious, life-changing disabilities which has a huge impact on their daily life. Post-stroke impairments and limitations may affect physical, communicational, cognitive and psychological functioning (RCP, 2016). The stroke care pathway can include several steps from acute care, early rehabilitation, secondary prevention, early supported discharge, community rehabilitation, systematic follow-up, long-term support and in some cases palliative care (RCP, 2016).
Physical activity after stroke
Physical activity is viewed as an important element of this pathway with different roles and functions in each step: It can function as a prevention, rehabilitation and secondary prevention tool, and it has multiple benefits affecting cognitive, psychosocial, emotional and physical states (Saunders, 2020). Physical activity is relevant across the whole care pathway, however, observation studies highlighted that stroke survivors engage with limited amount of physical activity and high level of sedentary behaviour (Fini et al., 2017). Physical activity behaviour is a modifiable factor in stroke care and current research highlights the need to develop interventions aiming to increase physical activity and reduce sedentary behaviour after stroke (Moore et al., 2018). Understanding factors that may positively or negatively influence the uptake, progression and maintenance of physical activity after stroke could allow the development of appropriately targeted interventions for this population. These factors include individual, social and environmental elements (see Table 1). Most of these factors are also modifiable, therefore future interventions could target some or all of these factors.

How can healthcare professionals/exercise psychologists help to increase physical activity after stroke?
In healthcare, there are many opportunities to assess and advise patients on physical activity (Patrick et al., 2009) and several national and international guidelines encourage health care professionals to do so. In stroke care, The National Clinical Guidelines for Stroke (2016) recommend that people with stroke should be offered self-management support based on self-efficacy, aimed at the knowledge and skills needed to manage life after stroke. People with significant changes in self-esteem after stroke should be offered information, support and advice, and considered for psychological interventions to increase their physical activity (Jones & Raizi, 2010). Health care professionals are well placed to encourage positive behaviour patterns early and help translate mobility and functional gains made in therapy to an increase in physical activity in the longer term. Helping relationships can be predictive of stages of change when it comes to physical activity (Cardinal et al., 2004).
Research evidence and best practice guidelines recommend that an initiative to increase physical activity is most effective when combined with behaviour change strategies (Donkers et al., 2018). Behaviour change strategies can be defined as techniques designed to specifically address one or more psychological determinants of behaviour (Michie et al., 2018) and they make up the active components used in behaviour change interventions (Michie et al., 2013). A review by Stretton et al. (2017) found that those interventions targeting stroke survivors which were based on exercise alone had no significant effect, or they were less effective than those incorporating behaviour change techniques as well. Moore et al. (2018) compared nine studies and found that interventions were viewed more effective if they went beyond simple demonstration and guidance of physical activity after stroke and used psychosocial support methods (e.g. action planning, social support and problem solving). Controversially, another systematic review by Kringle et al. (2019) found inconsistent results and the authors were unable to identify intervention approaches that are superior for modifying full-day activity patterns in stroke rehabilitation. When studies were looking at long-term physical activity and maintenance of physical activity behaviour instead of looking at the uptake of physical activity stage of behaviour change, Morris, MacGillivray and Mcfarlane (2014) found that interventions involving tailored counselling are likely to be effective.

Similar to the factors influencing physical activity uptake and maintenance, physical activity promotion is also influenced by several factors (Table 2) coming from the providers, the environment and the receivers. Currently, there is limited research regarding physical activity promotion behaviour after stroke, therefore, looking at the more extensive evidence from the general healthcare setting may better inform our understanding. Crisford et al. (2018) highlighted that further investigation of the strengths, opportunities and effectiveness of physical activity promotion within the various health professions and settings is warranted in order to create successful, targeted interventions.
Practical recommendations for health care professionals/exercise psychologists
There are areas of uncertainty and further work is required to improve our knowledge and understanding on the best ways to increase physical activity after stroke. However, based on the available literature and the discussion above, the following recommendations could help you to support individuals to increase their physical activity level:

- Stroke affects everyone differently, therefore an individually tailored approach is essential when it comes to assessing the physical activity needs of stroke survivors
- There are several modifiable factors that influence physical activity behaviour after stroke. Being aware and targeting the most relevant ones for each individual can improve the uptake and maintenance of physical activity after stroke
- There is a strong body of evidence supporting the implementation of behaviour change strategies into physical activity promotion. Familiarising yourself with these strategies can increase your own confidence and skills when it comes to supporting physical activity behaviour after stroke
- Reflecting on your own resources and organisational environment can help you to identify barriers and increase your own physical activity promotion behaviour
Reference
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Be sure to keep an eye out for more insightful studies coming from Dóra’s PhD in the future.


















